Intolerance to Enteral Nutrition
OVERVIEW
- Intolerance to enteral nutrition is characterised by excessive aspirates (>500mL q6h),vomiting, abdominal distension, constipation or diarrhoea
CAUSES
Patient
- GORD
- hiatus hernia
- gastroparesis/ileus
- pseudo-obstruction
- retroperitoneal haematoma/oedema
- bowel injury
- bowel ischaemia
- shock
- sepsis
- pancreatitis
- bowel obstruction
- hyperglycemia
- hypoxia / ischemia
- trauma
- burns
Mechanical
- NGT not placed in stomach
- kinking
- blockage
Drugs
- opioids
- sedation
- no prokinetics
- hyperosmolar formulas
ASSESSMENT
History
- sedation/analgesia: hold?
- history of symptoms
- discussion with surgeon
- search for sepsis, pancreatitis, MI, GI pathology, cause of shock
Examination
- to find above pathologies
Investigations
- AXR
- CXR (erect)
- CT abdomen
MANAGEMENT
General approach
- rule out bowel obstruction
- minimize drugs causing gastroparesis or ileus
- correct electrolytes
- start at low volumes with steady increases until goal rate achieved
- prokinetics
- consider NJ feeding
- TPN
Approach to gastric residual volumes >500mL q6h
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
LITFL
- CCC — Prokinetics
- CCC — Gastric Residual Volume
Journal articles
- Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007 Aug 7;13(29):3909-17. PMID: 17663503.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
2 Comments
Leave a Reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
I have been searching for help. My 36 year old son was born with cystic fibrosis. He had his first double lung transplant at 15. He had his second double lung transplant at 25. He under went a third double lung transplant at 35 this past September 13th 2020.
He has been in ICU at Toronto General Hospital for 5 months with many challenges. He has a trach, is on dialysis yet slowly he is getting stronger. The biggest problem has been feeding intolerance. Since October he has battled gas, bloating, diareaha, and is still not able feeds. Any recommendation would be greatly appreciated.
Hi Tanis, sounds like you and your son have had a really hard time of it. His situation sounds incredibly complicated and it’s not our place to offer specific advice here. I’m sure the team in Toronto would be looking at the usual options and it’s best to take it up with them.